Controlled trial of Hartmann's solution versus 0.9% saline for diabetic ketoacidosis

Yung, Michael; Letton, Georgia; Keeley, S.

doi:10.1111/jpc.13436

Cited by 33 publications

(78 citation statements)

References 14 publications

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“…[15][16][17]30 Consistent with our results, each of these trials found point estimates favoring faster DKA resolution with balanced crystalloids, although small sample sizes led to low power. [15][16][17]30 Mahler et al 15 randomized 45 adults with DKA and found Plasma-Lyte A led to higher plasma bicarbonate concentrations than saline after 24 hours (20 vs 17 mmol/L; P = .02). Van Zyl et al randomized 54 adults with DKA and found the median time to reach a pH greater than or equal to 7.32 was 540 minutes with lactated Ringer's and 683 minutes with saline (P = .25).…”

Section: Balanced Salinesupporting

confidence: 84%

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Clinical Effects of Balanced Crystalloids vs Saline in Adults With Diabetic Ketoacidosis

et al. 2020

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IMPORTANCE Saline (0.9% sodium chloride), the fluid most commonly used to treat diabetic ketoacidosis (DKA), can cause hyperchloremic metabolic acidosis. Balanced crystalloids, an alternative class of fluids for volume expansion, do not cause acidosis and, therefore, may lead to faster resolution of DKA than saline. OBJECTIVE To compare the clinical effects of balanced crystalloids with the clinical effects of saline for the acute treatment of adults with DKA. DESIGN, SETTING, AND PARTICIPANTS This study was a subgroup analysis of adults with DKA in 2 previously reported companion trials-Saline Against Lactated Ringer's or Plasma-Lyte in the Emergency Department (SALT-ED) and the Isotonic Solutions and Major Adverse Renal Events Trial (SMART). These trials, conducted between January 2016 and March 2017 in an academic medical center in the US, were pragmatic, multiple-crossover, cluster, randomized clinical trials comparing balanced crystalloids vs saline in emergency department (ED) and intensive care unit (ICU) patients.This study included adults who presented to the ED with DKA, defined as a clinical diagnosis of DKA, plasma glucose greater than 250 mg/dL, plasma bicarbonate less than or equal to 18 mmol/L, and anion gap greater than 10 mmol/L. Data analysis was performed from January to April 2020. INTERVENTIONS Balanced crystalloids (clinician's choice of Ringer lactate solution or Plasma-LyteA solution) vs saline for fluid administration in the ED and ICU according to the same clusterrandomized multiple-crossover schedule. MAIN OUTCOMES AND MEASURESThe primary outcome was time between ED presentation and DKA resolution, as defined by American Diabetes Association criteria. The secondary outcome was time between initiation and discontinuation of continuous insulin infusion. RESULTS Among 172 adults included in this secondary analysis of cluster trials, 94 were assigned to balanced crystalloids and 78 to saline. The median (interquartile range [IQR]) age was 29 (24-45) years, and 90 (52.3%) were women. The median (IQR) volume of isotonic fluid administered in the ED and ICU was 4478 (3000-6372) mL. Cumulative incidence analysis revealed shorter time to DKA resolution in the balanced crystalloids group (median time to resolution: 13.0 hours; IQR: 9.5-18.8 hours) than the saline group (median: 16.9 hours; IQR: 11.9-34.5 hours) (adjusted hazard ratio[aHR] = 1.68; 95% CI, 1.18-2.38; P = .004). Cumulative incidence analysis also revealed shorter time to insulin infusion discontinuation in the balanced crystalloids group (median: 9.8 hours; IQR: 5.1-17.0 (continued) Key Points Question Does using a balanced crystalloid solution instead of saline for fluid therapy in adults with diabetic ketoacidosis (DKA) lead to faster resolution of DKA? Findings In this subgroup analysis of 172 adults with DKA from 2 large cluster randomized clinical trials comparing balanced crystalloids and saline, the median time to DKA resolution was 13.0 hours with balanced crystalloids and 16.9 hours with saline, a significant difference. Me...

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Section: Balanced Salinesupporting

confidence: 84%

“…Van Zyl et al randomized 54 adults with DKA and found the median time to reach a pH greater than or equal to 7.32 was 540 minutes with lactated Ringer's and 683 minutes with saline (P = .25). Yung et al 17 randomized 77 children with DKA and found the geometric mean time to plasma bicarbonate concentration greater…”

Section: Balanced Salinementioning

confidence: 99%

Clinical Effects of Balanced Crystalloids vs Saline in Adults With Diabetic Ketoacidosis

et al. 2020

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“…Subsequent fluid management (deficit replacement) can be accomplished with 0.45% to 0.9% saline or a balanced salt solution (Ringer's lactate, Hartmann's solution or Plasmalyte) Fluid therapy should begin with deficit replacement plus maintenance fluid requirements. All children will experience a decrease in vascular volume when plasma glucose concentrations fall during treatment; therefore, it is essential to ensure that they receive sufficient fluid and salt to maintain adequate tissue perfusion. Deficit replacement should be with a solution that has a tonicity in the range 0.45% to 0.9% saline, with added potassium chloride, potassium phosphate or potassium acetate (see below under potassium replacement) .…”

Section: Clinical and Biochemical Monitoringmentioning

confidence: 99%

“…Subsequent fluid management (deficit replacement) can be accomplished with 0.45% to 0.9% saline or a balanced salt solution (Ringer's lactate, Hartmann's solution or Plasmalyte). 95,100,[108][109][110][111][112][113][114] • Fluid therapy should begin with deficit replacement plus maintenance fluid requirements.…”

Section: Deficit Replacement Fluidsmentioning

confidence: 99%

ISPAD Clinical Practice Consensus Guidelines 2018: Diabetic ketoacidosis and the hyperglycemic hyperosmolar state

et al. 2018

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“…In non-critically ill children undergoing major surgery, balanced solutions have been associated with less hyperchloremia and less metabolic acidosis when compared to 0.9% saline [20]. Moreover, a randomized controlled trial (RCT) on initial IV fluid in children with DKA showed Hartmann’s solution, when compared to 0.9% saline, to be associated with shorter hospital length of stay overall and a shorter time to normalization of pH in the subgroup of severe DKA [21]. However, in pediatric acute severe diarrheal dehydration, Kartha et al showed no difference between RL and 0.9% saline in biochemical or clinical outcomes [22] while Allen et al showed more rapid improvement of serum bicarbonate and faster resolution of dehydration with RL [23].…”

Section: Introductionmentioning

confidence: 99%

Impact of balanced versus unbalanced fluid resuscitation on clinical outcomes in critically ill children: protocol for a systematic review and meta-analysis

et al. 2019

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Background Isotonic crystalloid fluid bolus therapy is used in critically ill children to restore or maintain hemodynamic stability. However, the ideal choice of crystalloid remains to be determined. The most easily available and most frequently used crystalloid is 0.9% saline, an unbalanced crystalloid, that has been associated with hyperchloremic metabolic acidosis and acute kidney injury (AKI). Balanced fluids such as Ringer’s lactate (RL) were developed to be closer to the composition of serum. However, they are more expensive and less readily available than 0.9% saline. Few trials have found RL to be associated with more favorable outcomes, but pediatric data is limited and inconsistent. The objective of the present systematic review is to review existing literature to determine the effect of balanced versus unbalanced fluid bolus therapy on metabolic acidosis in critically ill children. Methods Using the Preferred Reporting Items for Systematic Review and Meta-analysis Protocols (PRISMA-P) guidelines, we will conduct a systematic review to retrieve all controlled trials and observational studies comparing balanced and unbalanced resuscitative fluids in critically ill children from age 28 days to 18 years old in any resuscitation settings. Search strategy was developed in collaboration with an experienced clinical research librarian. The primary outcome is the incidence and/or time to resolution of metabolic acidosis. Secondary outcomes included the incidence of hyperchloremia, AKI, duration of renal replacement therapy, vasopressors, mechanical ventilation, total volume of rehydration needed per day, extracorporeal membrane oxygenation, and length of stay and mortality. Study screening, inclusion, data extraction, and assessment of risk of bias will be performed independently by two authors. We intend to perform a meta-analysis with studies that are compatible on the basis of population and outcomes. Discussion Isotonic crystalloid fluid bolus therapy is a ubiquitous treatment in resuscitation of critically ill pediatric patients and yet there is no clear recommendation to support the choice of balanced versus unbalanced fluid. The present review will summarize current available data in the literature and assess whether recommendations can be generated regarding the choice of crystalloids or otherwise identify knowledge gaps which will open the door to a large-scale randomized controlled trial (RCT). Electronic supplementary material The online version of this article (10.1186/s13643-019-1109-2) contains supplementary material, which is available to authorized users.

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Controlled trial of Hartmann's solution versus 0.9% saline for diabetic ketoacidosis

Abstract: HS is an acceptable alternative to NS in DKA and may benefit those with severe DKA.

Cited by 33 publications

References 14 publications

Clinical Effects of Balanced Crystalloids vs Saline in Adults With Diabetic Ketoacidosis

Clinical Effects of Balanced Crystalloids vs Saline in Adults With Diabetic Ketoacidosis

ISPAD Clinical Practice Consensus Guidelines 2018: Diabetic ketoacidosis and the hyperglycemic hyperosmolar state

Impact of balanced versus unbalanced fluid resuscitation on clinical outcomes in critically ill children: protocol for a systematic review and meta-analysis

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